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10.09.16.00.htm 10.09.16.00. Title 10 MARYLAND DEPARTMENT OF HEALTH Subtitle 09 MEDICAL CARE PROGRAMS Chapter 16 Establishment, Operation, and Authority for Health Maintenance Organizations ― Medical Assistance Authority: Health-General Article, §2-104(b) 15-103, and 15-105, Annotated Code of Maryland
10.09.16.01.htm 10.09.16.01. 01 Scope.. These regulations govern health maintenance organizations―medical assistance, participating in the Maryland Medical Assistance Program.
10.09.16.02.htm 10.09.16.02. 02 Definitions.. A. "Capitation payment" means the sum of money paid in advance on a monthly per capita basis by the Department for a fixed benefit package.B. "Contract" means agreement between the HMO-MA and the Department.. C. "Department" means the Maryland Department of Health.. D. "Emergency services" means services that are covered under the contract and furnished to enrollees by providers who are not employees or agents of the HMO-MA and with whom the HMO-MA does not have
10.09.16.03.htm 10.09.16.03. 03 Provider Qualifications.. To participate in the Program, the provider shall:. A. Meet one of the following requirements:. 1) Be an organization as defined in § 1903(m)2)B)i) or (ii) of the Social Security Act;. 2) Be a health maintenance organization as defined by § 1903(m)1)A) of the Social Security Act.. B. Have a certificate of authority from the State Insurance Commissioner of Maryland, pursuant to Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland, as
10.09.16.04.htm 10.09.16.04. 04 Conditions for Participation.. A. When applying for participation in the Program, an organization shall demonstrate an ability to meet the requirements of these regulations.B. Professional and Administrative Standards. Providers shall have the professional and administrative ability and staffing to carry out contractual duties and responsibilities. These shall include the following:1) A full-time administrator;. 2) A demonstrated ability to deliver health servic
10.09.16.05.htm 10.09.16.05. 05 Covered Services.. A. The HMO-MA shall provide the full range of services available under the State Plan, except as limited by the contract.B. If the contract exempts the HMO-MA MA from financial responsibility for any services available under the State Plan, the HMO-MA may be required to arrange for, or refer enrollees to providers of, these services.C. The contract shall provide for automatic amendment, renegotiation, or termination, or all of the above, of the contract by
10.09.16.06.htm 10.09.16.06. 06 Limitations on Coverage.. See Regulation .05, of this chapter..
10.09.16.07.htm 10.09.16.07. 07 Authorization Requirements.. Approval by the Department shall be obtained for the following:. A. All subcontracts;. B. All contemplated changes in the HMO-MA benefit package;. C. All requests for increases in the individual HMO-MA contract enrollment limit; and. D. All changes not provided for in the contract..
10.09.16.08.htm 10.09.16.08. 08 Payment Procedure.. A. Payment for each enrollee shall be at a fixed capitation rate, except as provided in §G, of this regulation.B. The capitation rate paid by the Department shall be accepted as payment in full. Additional charge may not be made to the enrollee.C. Audited overpayments to the providers shall be refundable to the Department.. D. The HMO-MA shall conform to the Department's computer coding requirements.. E. No person who is enrolled in the HMO-MA under t
10.09.16.09.htm 10.09.16.09. 09 Recoveries and Reimbursements.. A. When an enrollee has a cause of action against any other person for medical expenses, the Department shall be subrogated against the other person to the extent of any payments made by the Department on behalf of the enrollee for medical expenses resulting from the occurrence which constituted the basis for the action against the other person.B. The HMO-MA shall include in its periodic reporting to the Department a complete disclosure of the
10.09.16.10.htm 10.09.16.10. 10 Cause for Suspension or Removal ― Imposition of Sanctions.. A. If the Department determines that an HMO-MA has failed to comply with applicable federal and State laws and regulations, the Department may initiate one or all of the following:1) Suspension of further enrollment;. 2) Withholding all or part of the capitation payments;. 3) Termination of the contract.. B. The Department shall give reasonable written notice to the HMO-MA enrollees and others who may be
10.09.16.11.htm 10.09.16.11. 11 Appeal Procedures.. Providers filing appeals from administrative decisions made in connection with these regulations shall do so according to COMAR 10.09.36.09.
10.09.16.12.htm 10.09.16.12. 12 Severability.. If any provision of these regulations or its application is held invalid in a court of competent jurisdiction, the invalidity does not affect other provisions or any other application of these regulations which can be given effect without the invalid provision or application, and for this purpose the provisions of these regulations are declared severable.
10.09.16.13.htm 10.09.16.13. 13 Interpretive Regulation.. Except when the language of a specific regulation indicates an intent by the Department to provide reimbursement for covered services to Program recipients without regard to the availability of federal financial participation, State regulations shall be interpreted in conformity with applicable federal statutes and regulations.
10.09.16.9999.htm 10.09.16.9999. Administrative History Effective date: July 9, 1975 (2:15 Md. R. 1077). Regulations .02D, .03A, .04C, F, and G, and .05 amended effective June 21, 1982 (9:12 Md. R. 1224). Regulation .02F amended effective May 15, 1981 (8:10 Md. R. 876). Regulations .03 and .04 amended effective December 15, 1978 (5:25 Md. R. 1854). Regulation .04A amended as an emergency provision effective November 8, 1996 (23:24 Md. R. 1676) amended permanently effective February 24, 1997 (24:4 Md. R. 291)
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